Live surgery must balance education with ethics of patient care
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Every ophthalmic surgeon agrees observing live surgery is an excellent educational experience. I would argue that it is a core requirement in the making of a surgeon.
In our training, we all start by observing experienced surgeons and watching videos. Then, we are allowed to participate in the surgery with ever increasing responsibility. I recommend to our fellows that they take the time to visit and observe experienced surgeons whenever possible. Vision is so important that most of us openly share and welcome colleagues into our clinics and operating rooms as observers. I served as a host surgeon in my own clinic and operating room (OR) throughout my career. Many key opinion leader (KOL) surgeons have one or more visiting ophthalmologists in their OR every time they operate.
While the challenges and ethics of having observers in one’s own OR are less challenging than when traveling elsewhere and operating in another surgeon’s OR on their patients with a large audience, I believe the core issues and ethics are the same. For me, it is always patients first. In all environments, the patient’s best interests are primary and other agendas secondary, including the educational goal. With this core principle, live surgery in any environment can be both ethical and educational.
I am not a professional ethicist, but putting patients first for an ethicist would include the following principles: beneficence, non-malfeasance, individual autonomy and justice.
Beneficence demands that the primary intent of the surgery be to benefit the patient. For me, this requires that the surgeon meets and examines the patient prior to surgery. This is the classical “laying on of hands” that establishes a physician-patient relationship. I have performed live surgery around the world, and in every case, I demanded that I be allowed to examine the patient before surgery and establish a physician-patient relationship, just like I would in my own practice. I have in some cases felt the surgery I was being asked to perform was inappropriate for a patient, that the patient was not emotionally a good candidate for a live surgery event or, in a few cases, that I would not be the ideal surgeon for the patient. In those cases, the surgery was canceled and another more appropriate patient was selected. Recognizing as a visiting surgeon in the OR that you have been asked to demonstrate the wrong surgery on an anxious, psychologically unprepared patient and that the correct surgery is one that you do not regularly perform should never happen, but I have observed it more than once in live surgery events.
The second core ethical principle is non-malfeasance, which in its simplest form can be translated into the core Hippocratic Oath: primum non nocere — first, do no harm. I aways determine if the surgery I am being asked to perform is indicated and appropriate. Is it the best surgery for the patient, and am I competent and comfortable performing it, including the management of complications in an unfamiliar OR with assistants who speak a different language in front of a large audience of my colleagues? I have seen many famous surgeons falter in the middle of a live surgery event, requiring a backup local surgeon to complete the case. In every live surgery performed outside one’s own OR, a local backup surgeon should always be available, and ideally the backup surgeon should also examine the patient before surgery, assist on the case and have informed the patient of their role.
This leads us to the third ethical principle, respect for patient autonomy. The patient deserves full informed consent regarding risks, benefits and alternatives as well as transparent disclosure as to who will do what during their surgery. They deserve to know that there will be an audience observing the surgery, that the surgery will be videotaped and that they will hear the surgeon explaining what he or she is doing each step of the way, often in a language the patient does not understand. Some patients after informed consent and full and transparent disclosure will choose not to participate in a live surgery event, requesting that a local surgeon perform their surgery on a regular OR day without observers.
The final ethical principle is justice, which demands equitable distribution of the benefits and risks of any activity. Patients in a live surgery event should not all be poor, represent a racial or gender minority, be prisoners or otherwise not represent the population of the country where the surgery is being performed.
These four core principles apply to surgery performed in any environment, whether it be a surgeon’s own OR or an OR far from home during a live surgery educational event. The dilemma for a live surgery event organizer and the surgeons participating in a live surgery event is that it is tempting to sacrifice one or more of these core principles that put patients first to enhance the educational experience, making education primary over the patient’s best interests. It is a significant challenge to create a live surgery event that puts patients first while providing great education, but I have experienced it many times. A perfect example is the live surgery educational events orchestrated around the world by Orbis. Much easier and possible with our modern telecommunication technology is to allow a surgeon to operate in their own OR on their own patients with a small local and larger global audience. The cases are live — unexpected complications occur — and seeing them managed by a master surgeon in their own OR with their own team is great education. Videotaping of cases, with or without editing, is easy, popular, appropriate and useful, but it lacks the interest generated when observing a live procedure with an unknown outcome. Just like it is much more fun to watch a live sporting event than one whose outcome is known, live surgery is more engaging. Learning can occur with either, but live surgery generates much more interest than an edited videotape.
An interesting hybrid was employed by the innovator Charles Kelman, MD. He created an event he called “Surgicus,” and I participated as a surgeon. The Surgicus surgeon operated at home but in advance agreed that a whole day of surgery would be videotaped and Dr. Kelman would edit and pick the cases presented later to the Surgicus educational event audience. Some perfect surgery was presented at the event as well as many interesting complications, some less well managed than others. A panel of KOL surgeons critiqued every case with the surgeon present as it was presented to meeting attendees. I found Surgicus as a surgeon, a member of the panels and a member of the audience to be an amazing educational format.
Observing live surgery remains a core requirement in every surgeon’s training and continuing education. It is the responsibility of our educational institutions, professional societies, industry sponsors and KOL educators to orchestrate live surgery programs that respect the core ethics of patient care while educating their colleagues.
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